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Path slides reread

Forums Cutaneous Melanoma Community Path slides reread

  • Post
    StevenK
    Participant

      My new dermatologist had my path slides reread by "his" guy, whom he trusts and there were a couple of changes. My depth grew from .60 to .66 and my mitotic rate got more specific from >1 to 4. The mitotic rate really scares me and makes it more likely that I'm going to go forward with an SND. I meet with my new surgical onc next week. It's been such a difficult and stressful road trying to get an SNB since my first surgical onc stopped returning my calls and I've had to find a new one.

      My new dermatologist had my path slides reread by "his" guy, whom he trusts and there were a couple of changes. My depth grew from .60 to .66 and my mitotic rate got more specific from >1 to 4. The mitotic rate really scares me and makes it more likely that I'm going to go forward with an SND. I meet with my new surgical onc next week. It's been such a difficult and stressful road trying to get an SNB since my first surgical onc stopped returning my calls and I've had to find a new one. Probably, since two months have passed already since my WLE, it makes sense to get a PET scan first. If cancer is in my nodes, it's had 2 months to grow. That will be one of the questions I ask my new surgeon.

      I guess the high mitotic rate means I'm more likely to experience a recurrance. Do those happen on the skin mainly or is it likely to be internal? It was nodular melanoma, the new path detrermined, so I was very lucky to catch it when it was still so shallow. I wish I had been given the SNB choice back when I had my WLE. I feel nervous and unsettled. Every few hours I check my lymph nodes, but so far they remain normal. Can't wait until I'm finally past all the initial staging stuff.

      Steve

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        Janner
        Participant

          Breslow from .6 to .66 is fine.  In fact, I'm amazed it's that close.  As far as mitotic rate, they currently lump anything 1 and above in the same category.  All the analysis they have done to predict which melanomas will spread hasn't shown a difference UNLESS they see <1 mitosis (lowest risk).  Nodular typically has a higher mitosis.  Breslow depth, to date, is still the MOST predictive indicator of whether or not a lesion will spread.  And .66 is small!  A PET scan will likely be of little value at this point.  Even if you did have melanoma in your lymph nodes, 2 months is a very small time period.  (Not mentally for us patients, but realistically for melanoma to grow).  PET scans do not pick up microscopic cancer.  That's why they do the SNB and not a PET scan for staging.  Tumors must be bigger than 6mm to be caught.  Even then, it's a crap shoot.  PET scans have high false positive and false negative rates.  You can certainly ask for a PET scan, but make sure your insurance will cover it.  For someone stage I, it might be a tough sell.  You know that the SNB is still "iffy" even if you do it now – because you've already had the WLE.  A surgeon can say he has the correct sentinel node, but after the WLE, there can be no guarantee of that.

          As far as a recurrence goes (which you're still unlikely to have), the most common place is in the lymph nodes.  You can also have subcutaneous mets (sub-q's).  You should watch both the skin area, scar area, and learn to palpate your lymph nodes after all the surgeries are done.  Only do the lymph nodes monthly.  More often doesn't give a good picture for change, and playing with the lymph nodes too often can cause them to swell for no reason.  You can get reactive nodes which are nodes that are benign, but swollen.  This can cause a lot of anguish for melanoma warriors. 

          Hang in there.  Despite all you read and worry, everything is still very low risk.

          Best wishes,

          Janner

          Janner
          Participant

            Breslow from .6 to .66 is fine.  In fact, I'm amazed it's that close.  As far as mitotic rate, they currently lump anything 1 and above in the same category.  All the analysis they have done to predict which melanomas will spread hasn't shown a difference UNLESS they see <1 mitosis (lowest risk).  Nodular typically has a higher mitosis.  Breslow depth, to date, is still the MOST predictive indicator of whether or not a lesion will spread.  And .66 is small!  A PET scan will likely be of little value at this point.  Even if you did have melanoma in your lymph nodes, 2 months is a very small time period.  (Not mentally for us patients, but realistically for melanoma to grow).  PET scans do not pick up microscopic cancer.  That's why they do the SNB and not a PET scan for staging.  Tumors must be bigger than 6mm to be caught.  Even then, it's a crap shoot.  PET scans have high false positive and false negative rates.  You can certainly ask for a PET scan, but make sure your insurance will cover it.  For someone stage I, it might be a tough sell.  You know that the SNB is still "iffy" even if you do it now – because you've already had the WLE.  A surgeon can say he has the correct sentinel node, but after the WLE, there can be no guarantee of that.

            As far as a recurrence goes (which you're still unlikely to have), the most common place is in the lymph nodes.  You can also have subcutaneous mets (sub-q's).  You should watch both the skin area, scar area, and learn to palpate your lymph nodes after all the surgeries are done.  Only do the lymph nodes monthly.  More often doesn't give a good picture for change, and playing with the lymph nodes too often can cause them to swell for no reason.  You can get reactive nodes which are nodes that are benign, but swollen.  This can cause a lot of anguish for melanoma warriors. 

            Hang in there.  Despite all you read and worry, everything is still very low risk.

            Best wishes,

            Janner

              StevenK
              Participant

                Thank you again, Janner. Lumping everything with a mitotic rate > 1 into the same category explains why my first surgical onc didn't feel the need to get the slides reread to obtain a specific number before he determined the percentage chance that it has spread to my nodes. He really didn't want me to get the SNB, which might explain why he ignored my requests to schedule it. Yeah, a PET scan doesn't sound sensitive enough. I'm not going to pursue it.

                As far as getting the SNB after the WLE goes, I've found and read a couple of studies that showed that it remains a very reliable procedure after the WLE. However, the complexity of the drainage on the face and neck may not have been taken into account by those general studies. Even if it is iffy, an SNB that finds nothing could reduce the already low percentage that it has spread and give me added peace of mind. Do I really want an invasive procedure that's not going to be definite, though? I'm going to let my new surgeon's experience guide me on that.

                The value of getting an SNB in my situation is a dilemna I've been stuck on for awhile now. Apparently, it is a raging controversy within medical circles. I'm terrified of getting the procedure done on my face and neck and so I'm not sure I'll be able to stubbornly insist on it if I encounter yet another doctor who's against it. My new derm is also leaning slightly against it. I could perhaps be persuaded into monitoring the nodes with ultrasound. I'm preparing a long list of questions for my new surgical onc.

                Best regards,

                Steve

                StevenK
                Participant

                  Thank you again, Janner. Lumping everything with a mitotic rate > 1 into the same category explains why my first surgical onc didn't feel the need to get the slides reread to obtain a specific number before he determined the percentage chance that it has spread to my nodes. He really didn't want me to get the SNB, which might explain why he ignored my requests to schedule it. Yeah, a PET scan doesn't sound sensitive enough. I'm not going to pursue it.

                  As far as getting the SNB after the WLE goes, I've found and read a couple of studies that showed that it remains a very reliable procedure after the WLE. However, the complexity of the drainage on the face and neck may not have been taken into account by those general studies. Even if it is iffy, an SNB that finds nothing could reduce the already low percentage that it has spread and give me added peace of mind. Do I really want an invasive procedure that's not going to be definite, though? I'm going to let my new surgeon's experience guide me on that.

                  The value of getting an SNB in my situation is a dilemna I've been stuck on for awhile now. Apparently, it is a raging controversy within medical circles. I'm terrified of getting the procedure done on my face and neck and so I'm not sure I'll be able to stubbornly insist on it if I encounter yet another doctor who's against it. My new derm is also leaning slightly against it. I could perhaps be persuaded into monitoring the nodes with ultrasound. I'm preparing a long list of questions for my new surgical onc.

                  Best regards,

                  Steve

                Jydnew
                Participant

                  Just wanted to say that it was 6 weeks between my husband's wide excision and the SNB, and that was deliberately planned that way, I suppose so that anything draining from the melanoma to the lymph nodes would finish up, so to speak, and not be just hanging out in the lymph system between the lesion and the nodes.  Obviously, I'm no expert, but wanted to say that 2 months probably isn't any big deal, so if you can get that SNB soon, I wouldn't worry about the lag time.

                  Also, his melanoma was 1.3, so he was an automatic candidate for the SNB, so again, a different story than your current diagnosis.  Good luck!!

                  Jydnew
                  Participant

                    Just wanted to say that it was 6 weeks between my husband's wide excision and the SNB, and that was deliberately planned that way, I suppose so that anything draining from the melanoma to the lymph nodes would finish up, so to speak, and not be just hanging out in the lymph system between the lesion and the nodes.  Obviously, I'm no expert, but wanted to say that 2 months probably isn't any big deal, so if you can get that SNB soon, I wouldn't worry about the lag time.

                    Also, his melanoma was 1.3, so he was an automatic candidate for the SNB, so again, a different story than your current diagnosis.  Good luck!!

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